Clinical Practice Guideline - Nutrition Strategies for Taste Impairment

Taste impairment is a reduced ability to sense flavors of food that can manifest itself in several ways.
Common diagnoses for impairment are1:

• hypogeusia - reduced ability to taste

• dysgeusia - distortion of taste

• ageusia - total lack of taste

Losing the sense of taste can have an effect on appetite, food choice and intake. The sense of taste can help
protect against weight loss, malnutrition and impaired immunity. Losing this “simple” pleasure, especially for
the elderly, can have an impact on enjoyment and quality of life. These alterations in taste can be caused from
physiological changes and/or medications. There are many physiological alterations that may negatively affect
the sense of taste including taste buds, saliva production or the nerve pathways. Since taste buds have a fast
turnover rate, with a life span of approximately 10-11 days, many taste disorders can resolve over time.
However, in conditions such as Bell’s Palsy, it may take several years to resolve itself.2

Taste impairment is a common patient complaint and nutrition strategies for taste impairment can be included
while performing the nutrition care process. Strategies for helping resolve taste impairment can then be
implemented into individualized intervention options for patients.

Assessment:
Taste impairment may be discovered during the assessment portion of the nutrition care process.
Considerations to taste impairment would be included when reviewing a patients medical history, medications
and performing a nutrition focused physical exam. Below are some of the common medical conditions
associated with taste impairments.2

Medical history: Common medical conditions associated with taste impairments

• Immune disorders: Acquired immunodeficiency syndrome (AIDS), Sjögren's syndrome

• Nerve disorders: Bell’s palsy, Multiple Sclerosis

• Chronic renal failure, liver disease

• Head trauma, headaches

• Psychiatric conditions (Depression, anorexia nervosa, bullemia)

• GI disorders: GERD, Regional enteritis, Crohn’s disease

• Trace metal deficiencies

• Tumor/lesions associated with taste pathways (Head and neck cancers)

• Vitamin deficiencies

Medications

Medications can effect the sense of taste by interfering with the chemical composition of the saliva, affecting
the transduction signal or directly damaging the taste ridges or receptors.

Some common medications that lead to taste impairment are:

• antibiotics

• ACE inhibitors (notably captopril)

• antithyroid drugs

• opiates

Typical tastes alterations from medications are described as a sweet, bitter or salty taste (3,7). Patients taking
multiple medications have been found to have interference with taste alterations. Some of these alterations
can lead to anorexia. It may be important to help the patient understand that discontinuation of medications
or procedures such as cancer treatment can improve their taste impairment over time1. Refer to Table 1 and
Table 2 to help assist patient needs regarding medicine-related taste changes.

Nutrition Focused Physical Examination

A Nutrition Focused Physical Examination is a critical component of the assessment for overall nutritional
status. Taste alterations that affect appetite and oral intake could be due to an underlying vitamin or mineral
deficiency. During this examination, a patient’s teeth, gums and tongue are evaluated for visual cues
indicating possible nutrition-related deficiencies. These cues can assist in identifying nutritional abnormalities
related to taste and appetite. Folate, niacin, riboflavin, B12, iron, zinc and vitamin C are vitamin and mineral
deficiencies that are related to the tongue and gums that may lead to taste abnormalities. It may be necessary
to utilize proper supplementation when these deficiencies are evident.

Zinc is a mineral that directly supports the proper perception of taste. Although zinc deficiency is uncommon
in the U.S., the deficiency may be revealed through a dietary loss or through a severe zinc deficiency. A
severe zinc deficiency may be evident due to other symptoms such as poor growth, poor wound healing,
alopecia, and severe dermatitis7. Zinc nutritional status is difficult to assess and when a severe deficiency is
suspected, it is best to refer a patient to their doctor.

Zinc supplementation recommendations above DRI are currently not recommended for increasing taste acuity
in most adults with zinc deficiency due to the adverse effects that can arise from excess zinc and the
potential for copper deficiency.(6,7) The best alternative to zinc deficiency is to identify those patients at risk
and estimate their daily dietary requirements. Individuals at risk for dietary zinc deficiency include:

• Individuals consuming a vegetarian diet

• Chronic alcoholism

• Chronic diarrhea

Obtaining a diet history during the nutrition care process can assist in assessing adequate nutrition. Providing
adequate calories, increasing their oral intake of proteins and fortified foods can help replete zinc and other
missing nutrients. Vegetarians should be advised to caution consuming large amounts of foods high in
phytates which reduces zinc uptake.

Taste Impairment Indicators

Besides reduced zinc, there are many reasons that lead to taste alterations and it could be beneficial to
quantify these taste alterations4. A taste impairment indicator can assist in establishing if a patient would
benefit from standard interventions or needs to seek advice from a specialist. Table 1 is a quantifiable
indicator tool that can help to identify taste impairments. The tool separates taste into four identifiers: flavor,
intensity, duration and frequency. Several steps can be used to help identify the symptoms of taste
impairment.

1. Identify whether the taste alteration is happening with one food item or with several items.

2. Assess flavor by four taste descriptions, “sweet, salty, bitter and sour”2

3. Assess intensity by a slight or “weak” distortion versus a severe or “strong” distortion

4. Assess duration by if a distortion lasts a “short” (seconds-minute) or “long” period of time (all day)

5. Assess frequency if distortion is happening “once” (one meal/snack) or “frequently” (throughout the day)

6. Results from Table 1 can help create individualized intervention options for the patient, reference Table 2

Table 1. Taste Impairment Indicators

Food item(s):

Flavor Intensity Duration Frequency

sweet weak/strong short/long once/frequent

salty weak/strong short/long once/frequent

bitter weak/strong short/long once/frequent

sour weak/strong short/long once/frequent

Referrals
Some persistent taste impairments are caused by conditions that are not remedied with standard
interventions and require specialists. These referrals would occur after standard interventions have not proven
to be effective treatment. These would include patients that have several taste distortions with most or all
food items throughout their day. These specialists can provide gustatory function testing, imaging, endoscopy
and biopsies2. The taste impairment conditions would include:

• Taste bud or taste receptor alterations: refer to an otolaryngologist (ENT doctor) or neurologist.

• Oral and/or perioral infections such as candidiasis, gingivitis, herpes simplex, periodontitis,
sialadenitis or dental procedures for tooth extractions or root canals: refer to a dentist.

• Tongue and esophagus or GI disorders that alter taste: refer to gastroenterologist.

• Severe zinc deficiencies: refer to patient’s physician

Intervention:
After performing the assessment portion of the nutrition care process, an RD can begin to provide a basis for
individualized diet intervention options. The diet modifications in Table 2 can be applied during the
intervention process to assist patients manage taste changes (8,10).

Table 2. Self care suggestions for taste impairments

Weak Strong
Sweet Add something sweet to meat dishes Add salt to decrease the sweetness of
including cranberry sauce, applesauce. sugary foods.
Salty Add fats, citrus or sauces to food. Use fewer condiments. Add sugar to
improve the flavor of salty foods.
Bitter Brush your teeth before eating Avoid beef if it tastes bitter or rotten. Use
plastic forks, knives and spoons metallic
taste is present.
Sour Marinate meats to change the taste. Drink highly flavored fluids such as
cranberry, grape or tomato with meals to
cover bad tastes
Other Suggestions
Strong Eat more foods that have strong smells Use less seasonings and spices. Boil foods
flavor such as fish. to make them more bland. Eat foods that
are bland including potatoes and bread.
No flavor Add more seasonings and spices to your Eat foods that are high in protein and have
foods such as oregano, basil, cinnamon alot of flavor such as chicken, beans and
and ginger eggs.
Dry mouth Try sucking on hard candies (sugarless is Use more condiments with foods such as
best) gravy, butter, sour cream, and bbq sauce.
Drink more water with your meals to help Eat small meals several times a day.
swallow foods or rinse away bad taste.
Let hot foods cool to work or room Eat cold foods like cheese or shakes
temperature before eating.

For immunocompromised patients, taste disturbances caused by radiation therapy, chemo, and infection can
have an impact on food intake leading to anorexia and/or cause a reduced compliance with cancer treatment.

Patients can obtain oral mucositis or xerostomia creating mouth sores and dry mouth decreasing oral intake.
The presence of erosions, ulcers and viral infections can be described as a burning or stinging in the mouth5.
Suggestions for patients with mouth sores and dry mouth include:

• Good mouth care management to remove food and bacteria

• Use a non-alcoholic mouth rinse

• Alcohol-based mouth rinses (e.g. chlorhexidine) are found to cause temporary taste disturbances9

• Use medication to alleviate mouth sore pain

• Blenderize foods, use creams or gravies to make it easier to eat

• Use a straw to direct fluids away from sores

 • Avoid spicy, acidic, hot or rough foods

• Use artificial saliva (such as Xerolube) to moisten mouth2

Overindulgence of excessive high calorie, high sugar or high salt foods to compensate for the bland

taste of foods should be considered in relation to current conditions such as diabetes and hypertension

conditions8. Adequate counseling and monitoring of patient’s taste sensations and food intake is necessary to
maintain nutritional status, preserve quality of life and reduce morbidity.

References
1. Nagraj SK, Naresh S, Srinivas K, et al. Interventions for the management of taste disturbances. Cochrane Database of
Systematic Reviews. 2014;(11).
2. Bromley, S.M. Smell and Taste Disorders: A Primary Care Approach. Am Fam Physician. 2000;61(2):427-436.
3. Bascones-Martínez A, Muñoz-Corcuera M, Bascones-Ilundain C. Side effects of drugs on the oral cavity. Medicina
Clínica (English Edition). 2015;144(3):126-131.
4. Henkin. R.J. Taste and smell function in chronic disease: A review of clinical and biochemical evaluations of taste and
smell dysfunction in over 5000 patients at The Taste and Smell Clinic in Washington, DC American Journal of
Otolaryngology. 2013;34(5),477-489.
5. Ponticelli E, Clari M, Frigerio S, et al. Dysgeusia and health-related quality of life of cancer patients receiving
chemotherapy: A cross-sectional study. European Journal of Cancer Care. 2017;26(2).
6. Pisano M, Hilas O. Zinc and Taste Disturbances in Older Adults: A Review of the Literature. The Consultant
Pharmacist. 2016;31(5):267-270.
7. Maret W, Sandstead HH. Zinc requirements and the risks and benefits of zinc supplementation. Journal of Trace
Elements in Medicine and Biology. 2006;20(1):3-18.
8. Nutrition Care Manual. https://www.nutritioncaremanual.org. Published 2018. Accessed April 29, 2018.
9. James P, Worthington HV, Parnell C, et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health.
Cochrane Database of Systematic Reviews. 2017;(3).
10. Rehwaldt M, Wickham R, Purl S, et al. Self-Care Strategies to Cope With Taste Changes After Chemotherapy.
Oncology Nursing Forum. 2009;36(2):E47-E56.